A
person does not exist in a vacuum; the, physical
The Ecology of Human
Performance: A
Framework for
Considering the Effect
of Context
Winnie Dunn, Catana Brown, Ann
McGuigan
Key Word: environment
in theon' and in practice, conte.A·t (as an area o/con-
cern to occupational therapists) has not receh'ed the
same attention as per/ormance components and per-
formcmce areas. The Ecologr 0/ Human Per/ormance
serves as a framework for considering the effect 0/
context. Context is described as a lensFoln Ichich per-
sons view their world The interrelations!llp a/person
and context determines which tasksfall within the
person's performa nce range. The Ecology of iiu man
Performance framework provides guidelines/or en-
compassing context in occupational therajJJ' theory.
practice, and resectrch.
Winnie Dunn, PhD. om FAOTA is Pmfessot' and Chair, Occupa-
tional Therapy Euucation. 3033 Rohinson, Universitl of Kan-
sas Medical Center, 3901 Rainhow Boulevard. Kansas Citl·.
Kansas 66160-7602.
Catana Brown, 1\01 CHI" is A'isisrant Professor, Occupational
Thet'apy Education, Univet'sitv of Kansas Medical Center, Kan-
sas City, Kansas.
Ann McGuigan. PhD is Assistant Pmfessor. Occupational Ther-
apy Education. Universitv of Kansas Medical Center. Kansas
City, Kansas.
Tbis article /l·U.\' acceptedfor PlliJIicutlOn '/aimeliT
Tbe American Journal of Occupational Tberapy
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environment as well as social, cultural, and tem-
poral factors all innuence behavior Taken to-
gether, those factors that operate external to the person
are identified as context for the purposes of this article.
Each person's contextual experience is unique, although
many elements are shared among persons.
Consider the unique way that adults talk to young
children. They may change the tone of their voices, care-
fully select their words, bend down to make themselves
smaller, or use gestures that animate the conversation.
Adults make these adartations hecause they recognize
the importance of context when talking to young chil-
dren, such as the level of the child's communication skills
or how the child might feel about talking to a big person.
lise of these ada[Jtive strategies by an adult speaking at a
work meeting would be considered inaPrropriate be-
cause the context of a work meeting dictates other com-
munication methods. The same need for contextually se-
lected behavior exists in manv realms of daily life. A
Catholic who attends services at a synagogue derives dif-
ferent meaning from the experience than does herjewish
friend. When a family eats at a fast-food restaurant, a
different repertoire of behaviors may he sanctioned than
if that same family went to a restaurant with menus at the
table. Context influences behavior and performance in
many ways; disciplines that address human behavior
must consider the effect of these contextual features on
target behaviors.
A recurring theme in the occupational therapv litera-
ture is the concert that environment (i.e., context) is a
critical factor in human performance. Despite this em-
phasis. the potential contribution of contextual features
in evaluation and intelvention relative to performance
components and performance aceas has ceceived little
attention. For example, occupational therapy has manv
assessment~ that examine muscle strength. social skills.
vestibular function, dressing, or use of leisure time. How-
evec, contextual features such as the physical qualities of
an environment, the cultural background of the person,
or the effect of friendships on performance are often
missing fcom assessment tools tvpicallv used in occupa-
tional thecapy. The Ecologv of Human Performance
(EHP) framework has been developed hv the occupation-
al therapv faculty members at the Cniversity of Kansas in
response to the lack of consideration for the complexities
of context. The framework provides a structure for think-
ing of context as a kev vaciahle in assessment and inter-
vention planning, while elucidating the inherent dangers
in examining perfocmance out of context.
Ecology is concerned with the interrelationships of
organisms and their environments. Occupational therapv
is interested in the interrelationship of humans and their
contexts and the effect of these relationships on perform-
ance; hence this ft'amework is entitled the Ecologv of
]9. 199-1 Human Performance.
595
 The EHP framework provides guidelines directed at
including contextual features in occupational therapy re-
search and practice (Mosey, 1992). It draws from occupa-
tional therapy and social science knowledge to contribute
a compJemenrary per:;pecrive of ecological prlnciples. As
a framework, it delineates and defines the relevant con-
cepts and describes relationships among variables. It pro-
vides direction for the development of specific frames of
reference concerned with context or the reexamination
of existing frames of reference and their attention to con-
text. The following literature review acknowledges the
major contribution of others in the development of this
framework and provides the groundwork for understand-
ing the EHP.
Relevant Literature from Social Science
The EHP framework is founded on and synthesizes the
work of scholars in several disciplines who have consid-
ered the interaction between person and environment.
Much of the original work was conducted by environmen-
tal psychologists who examined the interrelationshir of
the physical environment and human behavior or experi-
ence. In environmental psychology, persons are consid-
ered to be interdependent with their immediate environ-
ment; the focus of research is on the interaction of the
physical elements of a rerson's immediate environment
with behavior (Holahan, 1986; Wicker, 1979).
Although the EHP framework shares this emphasis
on examining the interdependent relationship between
the person and the physical environment, it expands the
concept of context-environment to include physical, tem-
roral, social, and cultural elements. Employing a broader
definition of environment allows researchers to make ex-
rlicit those elements that have frequently been left im-
plicit by the environmental psychologists. For example,
Wicker (1979) described the effect of settings on behavior
and detailed how behavior might be modified to be ap-
propriate for a particular environment. Implicit in his
analysis is the assumption of a shared concept of the
external environment. The use of context in the EHP
framework balances the emphasis on the external envi-
ronment presented in environmental psychology and
suggests that the researcher-practitioner consider what
the environment means to the person.
Hart (1979) conceptualized the environment as an
instrument of socialization. He presented the concept of
environmental competence as the "knowledge, skill and
confidence to use the environment to carry out one's own
goals and to enrich one's experience" (p. 343). Like other
environmental psychologists, he emphasized that the
process of learning about self and the environment is
interactional and he limited the concept of environment
to the physical environment.
The idea that context and person are interactional is
fundamental to the EHP. It is assumed that persons both
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affect and are affected by their Context. Although the
interactional relationship between person and environ-
ment is of primary importance to environmental psychol-
ogists, none has described this process as completely as
Bruner (1989). He developed the concept of transacrional
contextuaJism as a process in which the person con-
structs the self in the context of the environment. For
example, a child who grows up in a large family develops
a different construction of self than a child who grows up
without siblings.
Lawton's conceptualization of environment more
closely resembles that of the EHP than do those of other
environmental psychologists. He presented a broader
concert of environment that includes the personal, su-
prapersonal, and social as well as the physical (Lawton,
1982). Applying Murray's (1938) concept of environmen-
tal press to the physical environment, Lawton (1982) de-
veloped an ecological model of aging that describes the
dynamics of ecological change, competence, and environ-
mental press in which a person's environment affects
perceptions of competence. In this model, behavior is
thought to be "a function of the competence of the indi-
vidual and the environmental press of the situation"
(p. 43).
Hall (1983) and Zerubavel (198]) have examined the
concept of time as an aspect of environment. Both con-
sidered time as context. Hall portrayed time as a factor
that is different when persons live it and when they con-
sider it. He argued for a contextually bound, culturally
idiosyncratic, realistic concept of time. Zerubaval asserted
that time is a major parameter of environment and that
the two must mesh to produce a meaningful gestalt.
Csikszentmihalyi (1990) described "flow" experiences in
which persons are so immersed in a selected task that
they are unaware of the passage of time. These authors'
discussions of time as context provide excellent examples
of the im portance of considering time to be a com ronent
of context.
Several issues have been raised by those who have
considered the relationship of environment to behaVior.
Many authors have distinguished between the rheno-
menological and physical nature of the environment. The
EHP recognizes the role played by both. Gibson (1986)
discussed both these aspects in his consideration of the
relation between ecological context and visual percep-
tion. He suggested that the environment is both physical
and phenomenological in that persons perceive objects
in the environment by the affordances they offer. The
environment-context is meaningful to the person by
what it offers or allows the person. The EHP framework
incorporates this interrretive phenomenological per-
spective in its consideration of the relationship between
the person and context.
Developmental psychologists have also examined
the effect of environment on behavior. For the most part,
they have emphasized social aspects of environment.
July 1994, Volume 48, Number 7
 Bronfenbrenner's (1979) ecological model for human
development applied an ecological systems model to
human development It presented a system of social
relationships that provided the context for child develop-
ment. Bronfenbrenner also developed the concept of
ecological validity, in which he argued that research was
nor valid unless it was grounded in context. The EHP
framework might enable professionals to consider
whether therapeutic intervention could be valid if it were
nor grounded in context.
Vygorsky (1978) also examined the contribution that
social environment makes to development. Wertsch
(1985) summarized Vygorsky's principles by describing
how context could affect development in the theory of
the zone of proximal development. For Vygotsky, the
zone of proximal development was the distance between
a child's actual development and a higher level of poten-
tial development. Vygorsky argued that intervention dur-
ing periods of sensitivity might allow the child to develop
to a higher level than might have otherwise occurred, that
is, an alteration of the child's regular context could affect
development ,
The importance that the EHP framework places on
context is consistent with the emphasis placed on ecology
and context by Auerswald (1971), Auerswald's work on
ecological epistemology was among the earliest applica-
tions of an ecological perspective to therapeutic interven-
tion, He argued that the processing of information from a
holistic ecological perspective should replace simpler lin-
ear cause-and-effect thinking in therapeutic intervention
He identified a keynote of this kind of ecological thought
as the "concern with the context in which a phenomenon
occurs" (1971, p. 263), His position was that contextual
issues should be considered before any therapeutic inter-
vention began,
Relevant Occupational Therapy Literature
The environmental psychologists have contributeel to the
thinking of many occupational therapists, Kiernat (1992)
applied the Lawton-Nehamow ecological model in her
discussion of the environment as a modalitv, Barris
(1982) drew from the work of Wicker and Hall in her
conceptualization of environmental interactions, Howe
and Briggs (1982) descrihed an ecological svstems model
for occupational ther-apv that included the theories of
Auerswald, Bronfenbrenner, and Wicker, whereas Spen-
cer (1991b) used the ideas of HalJ and Lawton in her
discussion of physical environment and performance,
The terms environment and conlexl are used inter-
changeably in the present review, dependent on the word
contained in the original work. Although the occupation-
al therapy literature has most commonly used the term
environment, more recent authors have used the term
context. The latter ter-m was chosen for the EHP frame-
work because context encompasses more of the person's
The American Journal 0)' Occupational Therapy
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physical, social, and phenomenological experience.
The concept of environment in theoretical occupa-
tional therapy literature is typically explained from two
positions. In one, the environment is described primarily
as a tool employed by the therapist in the intervention
process. For example, Llorens (1970) defined occupa-
tional therapy intervention as the provision of environ-
ments that assist persons whose developmental cycle has
been disrupted, Fidler and Fidler (1978) explained that
persons develop skills and mastery through interaction
with the human and nonhuman environment. She appre-
ciated the individuality of this in teraction and recognized
the influence of social and cultural norms, King (1978)
described intervention as the use of the environment to
elicit adaptive responses.
In the other position, the relationship of the environ-
ment and the per-son is char-acterizec! from the perspec-
tive of gener-al systems theor-y, The application of gener-al
systems theory to occupational ther-apy has facilitated the
understanding of person and environment interaction,
Reilly (1962) was the fir-st to apply the constr-ucts of gener-
al systems theory and to include the r-ules of hier-archy as
organizing principles. The person and envir-onment ar-e
ther-efore viewed as interdependent, interacting through
a system of input, output, and feedhack.
General systems thcor-y and hierarchical stl"Uctures
provide a framework for the Model of Human Occupation
(Kielhofner- & Burke, 1980) The components of the envi-
ronment ar-e identified as objects, per-sons, and events
that again interact with the person in an open system.
Kielhofner and Burke included throughput as an element
of the system that is made up of three hierarchically
arranged suhsystems: volition, habituation, and perform-
ance, Bar-ris (1982) used the framework of the Model of
Human Occupation to clarify environmental properties
and their- influence on the person.
Occupation science organizes the study of humans
as occupational beings through the Model of Human Sub-
systems That Influence Occupation (Clark et a!., 1991)
This model, hased on general systems theory, represents
the per-son as six hierarchically arranged subsystems that
inter-act with the environment in an open system,
Hmve and Briggs (1982) developed the Ecological
Systems Model. which uses general systems theory to
portray inter-connections of the per-son and the environ-
ment as concentric circles with the person at the center
surrounded hy environmental layers. They detailed the
model's view of function and dysfunction, which consid-
ers both the person and the environmental context,
In defining occupation, Nelson (1988) described the
dynamics of occupational form and occupational per-
formance within the framework of a system, Occupation-
al form was defined as "an objective set of circumstances,
independent of anel external to a person" (p. 633). Nelson
emphasized that performance can only be understooel in
terms of the occupational form. Moreover, occupations
597
 arc characterized as occurring at different levels.
Christiansen (1991) discussed the effect that general
systems theorv has had on organizing the complex con-
cerns involved in occupational therapv. General systems
rheory has allowed rhe~e complexiries ro be undersrood
while avoiding reductionistic views that oversimplify
phenomena.
General systems theory is congruous with the EHP.
However, the conceptualization of the EHP is distin-
gUished by a nonlinear, dynamic perspective. Dynamic
principles describe systems as multiply determined, com-
plex, and self-organizing (Thelen, 1992). They eschew
schemas and static programs and emphasize variability.
Persons may tend toward certain modes, behaviors, or
patterns; however, small changes in the person or con-
text alter these tendencies. Persons self-organize by
adapting to these changes. When persons are unable to
successfully self-organize, the occupational therapist pro-
vides interventions that encompass the complex relation-
ship of the person and his or her context. In dynamic
systems, hierarchies can exist to suggest patterns but are
not requisite pans of the system.
The EHP provides a framework for examining situa-
tions that occupational therapists encounter every day.
For example, the framework illustrates why some people
in the intermediate stages of Alzheimer's disease may be
able to live in a horne environment, whereas others may
be more comfortable in a nursing facility (i.e., the sup-
ports available to enable the person to function safely at
home may be available to the first person, but not to the
second one). The framework also illustrates why nOt all
persons require prevocational training before they can
work competitively (i.e., the contextual supportS and
cues available in the actual work: environment may
enable the person to perform the work task more con-
sistently than in simulated task performance, which
does not contain these supports). The EHP deciphers the
variance in disruption of daily life that persons expe-
rience with disabilitv, illness, or stress from a contextual
perspective.
Recently, context's significance has received more
attention in the occupational therapy literature. Mosey
(1992) included context as one of three categories in
occupational therapy's domain of concern. She classified
age and environment as the components of context that
"provide the persrective from which performance com-
ponents and occurational areas are viewed relative to the
individual (1992, p. 260). Schkade and Schultz (1992)
described occu pa tional ada pta tiol1 as a fl'ame of reference
that gives equal importance to the environment and the
person. Occupational adartation is organized by a holis-
tic, non hierarchical approach; however, the linear per-
spective of occupational adaptation distinguishes it from
the nonlinear view of the EHP framework.
Several authors have strongly advocated the inclu-
sion of context in occupational therapy assessment. Dunn
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(1993) recommended using a contextual approach to as-
sessment so that the assessment is relevant to the person
and addresses the rerson's wants and needs. Kiernat
(1990) stated that environment is a factor in disability and
muse be conSidered when assessing function. Fisher
(1992) advocated for the recognition of occupational
therapy's unique perspective of function in the assess-
ment process. She emphasized the imponance of consid-
ering the meaningfulness of the measure and placing the
assessment within context. Ethnographic methods have
been proposed as a means of including context in occupa-
tional therapy assessment (Spencer, Krefting, & Mat-
tingly, 1993). Proponents of ethnography have suggested
that these methods can present a more realistic analysis
of the person relative to the expectations within a setting.
The current literature has also discussed the applica-
tion of contextual elements. Spencer (1991a) studied the
relationship of social and cultural factors to independent
liVing alternatives. Barney (1991) identified culture as a
basic contextual determinant when providing services to
older adults in need of assisted living.
In summary, although the occupational therapy lit-
erature has consistently included environment as a salient
feature of performance, no author has proposed a frame-
work for systematic consideration of environment-
context. It is imperative that occurational therapy begin
to directly address the features of context; this knowledge
will broaden perspectives On successful intervention pos-
sibilities.
The EHP Framework
The EHP was developed to provide a framework for inves-
tigating the relationship between important constructs in
the practice of occupational therarY: person, context
(temporal, rhysical, social, and cultur3l [American Occu-
rational Therapy Association, in press j), tasks, perform-
ance, and therapeutic intervention, to better understand
the domain of human performance. The primary theo-
retical postulate fundamental to the EHP framework is
that ecoJogy, or the interaction between person and the
environment, affects human behavior and performance,
and that performance cannot be understood outside of
context.
The person in this framework includes one's expe-
riences and sensorimotor, cognitive, and psychosocial
skills and abilities. The person is represented by a simple
stick figure in the circle (see Figure 1). The circle sur-
rounding the person represents the person's context
(physical, temporal, social, and cultural features); the
only way to see the person is to look through the context.
In Figure 1, a wedge has been cut out of the context to
make the person easier to view. The ellipse in the dia-
gram is the cut edge, enabling the reader to see the
person. In this model, it is impossible to see the person
july 1994, Volume 48, Number 7
 <:ONTEXT
Figure 1. Schemata for the Ecology of Human Performance framework. Persons are embedded in their contexts. An infinite
variety of tasks exists around every person. Performance results when the person interacts with context to engage in tasks.
without first seeing the context.
The circles with the Ts inside represent the tasks thar
are available to pecsons. Tasks ace clefined as objective
sets of behaviors necessary to accomplish a goal. Every-
one has the opportunity or the possibility of performing
myriad tasks. PersOns use their skills andabiJities to focus
attention on specific tasks from these possibilities.
When persons use their skills and abilities to per-
form tasb, they use enviconmenta! cues and feature., to
sU{lpon performance. Figure 2 iJlustcates a typical person
embedded in a context sUPDorting regular behaVior, who
has a particular focus on a particular area of perfOl"m~lnce.
For example, a person may notice that the red light is on
at the street curner, indicating the need to stop. A per-
son's contexts are continuously shifting; as Contexts shift,
the behaviors necessary to accomplish a goal a 1.'0 change.
When persons use their context to support pedorm-
ance, it is like using the lens within the eye to get a
perspective on the world. As Figure 2 indicates, the con-
textual lens interacts with persons' skills and abilities to
enable persons to perform certain tasks The ['esulting
scope of action is called the performance l-ange (sec Ap-
pendL'() Persons view different pOtential tasks through
their contextual filter, the accumulation of their expe-
riences, and their perceptions about the physic31. social,
and cultural features of their current performance setting.
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TASK
One person might look toward being a downhill skier and
another might look toward being a writer or a cook, but
eVCI)'one looks through a context to derive meaning
about needs or desires.
Occupational therapy also considers a person's life
roles Figure 3 illustrates how roles may be characterized
in this model: it displays three roles (cook, mother, and
\vife) as a constellation of tasks; some of these roles ovC!'-
lap. Each person who has the roles of Wife, cook, and
mother includes a unique configuration of tasks in each
role as a consequence of her skills and experiences and
[he demands of her context. For example, if one person is
a gourmet cook, she might have more tasks in the cook
configuration than another person \vho uses a microwave
oven to prepare meals or goes to restaurants.
The temporal context is also relevant to role charac-
terization. For example, a child's role as cook might in-
vo]ve sim{ller recipes than an adult's. A person who has
sustained an acute injuly, such as a broken leg, may adapt
the role of cook until it is possible to go out to restaurants
again, whet'eas a person with a chronic disability, such as
a head injuly, may need to learn comp]etely new cooking
strategies. A person's configuration of the roles is based
on the person's skills, abilities, context, and desires.
A person may have more limited skills and abilities
but be embedded in a regular context [hat typically sup-
599
 Figure 2. Schemata of a typical person within the Ecology of Human Periormance framework. Persons use their skills and
abilities to look through the context at the tasks they need or want to do. They derive meaning from this process. Periorm-
ance range is the configuration of tasks that the persons execute.

Figure 3. Illustration of roles in the Ecology of Human Periormance framework. Life roles are a constellation of tasks. Per-
sons have many roles; some tasks fall into more than one role. These role configurations are unique for each person.

600 .lull' 1994, Volume 4/1. Number 7

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 pons performance. This person may have the same possi-
ble cues and supports available in the context as that of
the person in Figure 2, but the performance l"angc is
narrower because this person does not notice all the cues
and supports. When a person has a more limited set of
skills and abilities, then the person may either derive less
meaning from the context or may not have the personal
resources to suppOrt performance (see Figure 4). This
person may not have the necessary physical capacities
(e.g., a person who is blind may nor be able ro drive), may
not pick up the cues the context provides (e.g., a child
may fail to recognize that another child is trying the en-
gage him or her in play), or may not know how to take
advantage of contextual features (e.g., a person may stand
in a full-service lane at the grocery StOl'C with onlv four
items wlwn an ex[)ress lane is available). Each condition
mal' result in a more limited pCI'formance ['ange. The
wsks that are [)ossible are limited because the person is
not able to use the resources that might be available to
support performance in the context.
For exam pic, if a person is learning to ski, all of the
contextual features arc available to support skiing but the
person initially lacks the skills to perform the skiing beha-
viors and so has a mOl'e limited performance r;l1lge. An
adult with developmental clisabilities mal' need tl'anspor-
tation to work. The bus system is available in the context;
all the features <Ire there to allow persons to use the bus
Figure 4. Schemata of a person with limited skills and abilities within the Ecology of Human Performance framework. Al-
though context is still useful, the person has fewer skills and abilities with which to look through context and derive meaning.
This lack limits the person's performance range.
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to get to work, but the person may nor have the skills
necessary to use those features to an advantage, so the
performance range is limited. A child may have attention-
al defiCits and limited social skills. Although the context
for this child has the same cues that it has for every other
child at school, the child who has poor social skill devel-
opment may not be sensitive to these cues. When the
teacher frowns, this child may not understand its mean-
ing, may nor notice, or may misinterpret the frown and
thus may behave in a way that is viewed as inappropriate
for the context of the school d<lY. Consequently, the per-
formance range is limited by the inability to take ad-
vantage of thc cues or by the irrelevance of the cues to
the person. When a person has limited skills and abili-
ties. these limitations can he compounded by inability to
use contextual features to an advantage in suPPOrt of
perfomlance.
Sometlmes, thne is a more limited contextual envi-
1'Onment availahle to the person, but the person pos-
sesses tvpical skill::; and abilities (see Figure 5). For exam-
ple, a gourmet cook mav have extensive cooking skills,
hut in a kitchen with only a toastel' oven, that cook has
limited ability to demonstrate those skills and abilities. A
skillful downhill skiel' has a difficult time demonsmHing
those skills in the t!'Opics: the person must travel tu a
more contextually I-elevant 10Guion.
Persons with dis<lbilities sometimes have limited
601
 CD
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Figure 5. Schemata of a limited context within the Ecology of Human Performance framework. The person has adequate
skills and abilities, but the context does not provide resources needed to perform. In this situation, performance range is
limited.
skills and abilities and are also in an impoverished context
(e.g., a person with severe mental illness who is also
homeless). They do not have a context that provides
them with the salient cues and the objects or events that
are relevant to them to support pcrformance. Perform-
ance of daily life tasks, work, or leisure activities in this
situation becomes even more complex.
Therapeutic Intervention Within the EHP
Occupational therapy is most effective when it is imhed-
ded in real life. If occupational therapists evaluate individ-
ual performance without considering the context of the
performance, there is a great risk of interprcting the be-
havior inarpropriately. Misinterpretation can lead to in-
appropriate choices about therapeutic intervention. For
example, consider an occupational therapist working
with a young woman and her daughter, who was physical-
ly ready to feed herself. The woman resisted thc occupa-
tional therapist's repeated suggestions to use more inde-
pendent eating strategies. Upon completing a home visit,
the occupational therapist discovered that the mother
only knew how to intcract with her daughter during meal-
time. At other times, the child sat on th~ floor with toys,
but with no direction or interaction. The horne visit made
it clear to the occupational therapist that the mOther was
reluctant to give up her only time of interaction with her
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..
... :.':
daughter. This new insight helped the occupational
therapist redirect therapeutic efforts so that the mother
and child could play together in a manner that was satiSfy-
ing to bOth. By nOt considering context, this occupational
therapist would have put this mother in the difficult situa-
tion of having to compromise her relationship with her
daughter by following the therapist's suggestions. Addi-
tionally, by not considering context, the therapist would
have taken the risk that the child would not make pro-
gress because the mOther might not have followed her
suggestions.
A naturalistic study by deVries & DeJc:spaul (1989)
examined context and the experiences of persons with
schizophrenia. They concluded that knowledge of con-
text provided a new clinical tool. In one example, a man
with schizorhrenia was having severe problems with hy-
pertensive illness Clinical investigation to determine the
cause of his high blood pressure was puzzling. An analysis
of this man's context revealed that he worked as a dish-
washer and became extremely anxious when he had to
sort silverware during the lunch rush. The clinician was
able to use this contextual information to convince the
employer to change the employee's work tasks. Conse-
quently, the man's blood pressure decreased to near
normal.
Eelationships among the EHP framework and the
variety of interventions available to the occupational
July 1994, Volume 48. Number 7
 therapist are shown in Figure 6. Within this framework,
therapeutic intervention is a collaboration among the
person, the family, and the occupational therapist direct-
ed at meeting performance needs. Figure 6 displays five
alternatives for therapeutic intervention; the Appendix
contains definitions 0[' each therapeutic intervention.
Establish or Restore
The first therapeutic intervention alternative is to estab-
lish or restore (remediate) the person's skills and abili-
ties. In this category, the occupational therapist identifies
the person's skills and the barriers to performance and
designs interventions that improve the person's skills and
abilities. The occupational therapist, person, and family
might be concerned with reestablishing the person's role
in the family, and so might work on coping skills or phys-
ical endurance to enable the person to perform tasks
related to the family role. Restorative approaches are
common options chosen by therapists, particularly within
the medical model, which considers what is wrong with
the person and sets a plan to correct the problem. This
approach is adapted, especially with young children, to
include establishing needed skills for function. For exam-
ple, a therapist might work on the muscle tone of a child
with Down syndrome so that the child can move about to
ESTABLISH/ ADAPT
RESTORE
ALTER
Figure 6. Illustration of therapeutic interventions within the Ecology of Human Performance framework. The arrows indicate
the variables that are affected by each intervention.
The American Journat o/Occupationat Therap)!
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play with friends. Adults use these approaches within
their own lives when they learn a new skill or when they
work to restore a lost function (e.g., increasing range of
motion in a joint after removing a cast).
Even when the focus of intervention is on skill devel-
opment, context is still important. For example, Abreu
and Hinojosa (1992) suggested that predictable environ-
ments provide the feedback necessary to correct motor
behaViors. Toglia (1992) explained that an understanding
of the interactions of person, task, and environment is
essential to effective cognitive rehabilitation strategies.
Alter
The second therapeutic intervention alternative is to alter
the actual context in which persons perform. This inter-
vention emphasizes selecting a context that enables the
person to perform with current skills and abilities. The
person can be placed in a different setting that more
closely matches his or her current skills and abilities,
rather than changing the present setting to accommodate
the person's needs. The occupational therapist would
consider the person's skills, abilities, and difficulties and
find a context that was compatible with this performance
profile. The important feature of the alter inte[V'ention is
that the therapist does not set out to correct the person
CREATE
PREVENT
603
 or the environmene; instead, the therapist is looking for
the best match between the person and current contextu-
al features available. Allen (1992) acknowledged the lack
of direction for occupational therapists working with per-
sons beyond the acute phase of illness who must live with
functional limitations. Her frame of reference provides
gUidelines for making the best fit for persons with cogni-
tive disabilities and available contexts.
Fairweather (1980) used the alter strategy in his
Lodge Society, a community program for persons with
severe meneal illness. He was concerned that persons
who were able to succeed in jobs at the hospital were
unsuccessful at work in the community because of the
intolerance for behavior that was viewed as deviant. One
strategy was to create janitorial crews that worked at
times and in settings where their contact with others was
limited.
Another example involves a person who has low as-
sertiveness ability and needs to buy a car. Although the
therapist could work on assertiveness skill development
or visit the car dealer to offer some adaptations to the
process to facilitate the person's purchase, an alternative
that uses the alter interveneion option would be for the
therapist to suggest that the person buy a car at a dealer-
ship that employs the no-haggling approach. Some man-
ufacturers market their sales strategy as one that mini-
mizes the need for assertiveness because there is one
price for their cars and no negotiating is necessary. The
therapist does not have to change the context and the
person can succeed with currene skills to purchase the
car.
Adapt
The occupational therapist can also adapt the contextual
features and task demands to sUPPOrt performance in
context. When therapists adapt; they design a more sup-
portive context for the person's performance. Therapists
might enhance some contextual features to proVide cues
and reduce other features to minimize distractibility and
make the task more possible for the person. When chil-
dren are distractible, therapists suggest shorter assign-
ments for their seat work in class. When an adult with
severe disabilities needs to manage the home environ-
ment, the therapist might select an environmental con-
troJ unit. Therapists adjust desk and table configurations
to meet individual needs. They might change a desk's
height to match the person's postural support needs or
might find a lower table in the dining area for someone
whose ethnic background suggests preference for a lower
eating surface. Many persons use stick-on notes to help
them remember things they need to do. Persons whose
vision is failing may purchase hard-cover novels because
they have larger prine than paperbacks. Buning and Hanz-
lik (1993) reported a single-subject study in which the
person's context was considered in technological adapta-
tions. In this case, computer technologies were used so
604
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that a doctoral student with severe visual impairments
could complete her dissertation.
Prevenl
The fourth therapeutic intervention option is to prevent
the occurrence or evolution of maladaptive performance
in context. Sometimes, therapists can predict that certain
negative outcomes are likely unless intervention is pro-
vided. Therapists can create interventions to change the
course of events by addressing person, context, and task
variables to enable functional performance to emerge.
This view is supported by Coulter (1992) who proposed
that prevention efforts in mental retardation must take an
ecological approach that focuses on the interaction be-
tween persons and their environment. Department man-
agers employ a prevention approach when they provide
an orientation for newly hired employees; managers do
not wait until the employee faces a problem to instruct
them in proper procedures. Runners who stretch before
running are employing a prevention approach. Occupa-
tional therapists teach persons with spinal cord injuries
how to adjust their position frequenely to prevent con-
tractures and decubitus ulcers Therapists also provide
lifting classes in industrial settings to prevent work injur-
ies. Therapists can construct a map of community ser-
vices for a person with severe meneal illness who is mov-
ing to a new apartment area to prevent him or her from
feeling socially isolated. Prevention approaches antici-
pate possible and likely problems and change the course
of activities to increase positive outcomes. Prevention
approaches are good options for persons with long-term
conditions that lead to secondary problems; the temporal
context is relevant to these person's outcomes.
Create
The fifth therapeutic intervention option is creating cir-
cumstances that promote more adaptable or complex
performance in context. This therapeutic intervention
does not assume that a disability is present or that a
disability has the potential to interfere with performance.
The person or family seeking assistance may see the
problem from a functional performance standpoint, not
from a disability standpoint. The therapist participates by
providing expertise to enrich contextual and task expe-
riences that will enhance performance. Circumstances
that do not presume disability are constructed; this is
what distinguishes the create intervention from the
prevent intervention, which addresses precluding the
occurrence of a problem that is likely to arise. Early inter-
vention programs are common examples of community-
based programs that have an enriching philosophy;
thera pists use their expertise to plan age-appropriate
tasks that embellish the young children's development.
Therapists might also participate in the development of
living communities for elders that provide varied and
July 1994, Volume 48, Number 7
 stimulating activities. These community settings do not
presume their consumers have disabilities. They are de-
signed to make the best possible use of environment to
enhance living and development. For example, a large
building complex may have many signs to lead visitors
and workers to correct locations efficiently, not because
there are presumed disabilities, but because signs make
the environment easier for everyone. When adults play an
icebreaker game at the beginning of a party they are
creating an enriched environment for socialization.
Occupational therapists have many therapeutic
choices with each person they serve, and at each point
along the therapeutic relationship. Therapists often em-
ploy several intervention approaches either simulta-
neously or across time. Table 1 shows two examples of
how an occupational therapist might deal with a person
and family who need occupational therapy services from
all of these approaches. When occupational therapists
include context in the total perspective, it creates possi-
bilities; when persons are viewed out of context, viable
options are lost,
Directions for Future Work
The EHP proposes the relationships among the key varia-
bles of person, context, tasks, and performance, Within
the domain of concern of occupational therapy, context is
only relevant as it relates to human performance,
Mosey (1981) indicated that a frame of reference
must describe postulates that allow application to prac-
tice and offer specific guidance for intervention. Scholars
will therefore need to refine these constructs by assessing
their adequacy and answering practice-oriented ques-
tions. Several lines of study provide important initial in-
formation that will refine current frames of reference that
affect occupational therapy, develop new frames of refer-
ence, and create new assessment and intervention
strategies.
Several questions emerge as fundamental to the in-
vestigation of basic relationships proposed in this frame-
work. A primary question is: How do we capture contex-
tual features objectively, and how do we then decide
which features are salient for particular performance situ-
ations' We must also determine how a contextual feature
becomes relevant for a particular person. There are many
more contextual features available to persons in a particu-
lar context than are noticed or used by a person for
successful performance. In particular performance situa-
tions, we need to determine which contextual features
support or create barriers to performance, Are there par-
ticular contextual features that contribute to a person's
resilience'
Occupational therapy assessment strategies also
need to consider context. It will be important to deter-
mine whether standardized functional assessments are
valid for capturing what is actually known about the per-
The American Journal of Occupational Therapy
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Table 1
Case Examples Applying the Ecology of Human
Performance Framework
Area Addressed Strategy Emp]oyedlInformation
CASE 1
Background Mis 15 months old; he has twO older siblings
and both of his parents living in his home, He
has very low muscle tone and a developmental
delay and his family wants him to play and so-
cialize.
Establish/Restore The therapist decides to work on M's eye con-
tact and vocalizing as ways for the family to
know that M is paying attention to them.
Alter The therapist suggests that the family enroll M
in a part-time day care program so he can have
the stimulation of the other children playing as
a way to learn play skills,
Adapt The therapist talks to the family about moving
the toys closer, having the siblings move closer
when they play with M. The therapist works
with the siblings to help them learn how to
change their voice tone so that M can pay at-
tention easier,
Prevent The therapist decides to work on functional
communication strategies to prevent M's frus-
tration at socializing, The therapist works with
the family to pick some simple gestures and
sounds that everyone recognizes as communi-
cation signals from M, so he can get some basic
needs met,
Create The therapist and parents discuss the usefulness
of getting together with other families from the
church that have similar aged children for a
family gathering, This will be a positive social-
ization expe.-ience for all members, and in-
volved M in a typical socialization opportunity.
CASE 2
Background Ms. T is a 75-year-old who has had a right hemi-
sphere stroke. She lives with her son and
daughter-in-law and two grandchildren.
EstablishiRestore The therapist decides to work on func[\onal
range of motion for reaching and stepping.
Alter The therapist and Ms, T discuss her need to so-
cialize and Ms. T expresses concern over her
usual socializing in the quilting club, which ex-
pects a certain level of performance, The thera-
pist suggests Sunday school as a place to so-
cialize that doesn't reqUire the fine motor
control.
Adapt The therapist brings clamps to help her with he,-
stitching so that she could still do some stitch-
ing, The therapist brings her a stocking darner
and velcro to attach to key items in the bath-
room when she expressed desire to dress and
complete personal hygeine.
Prevent The therapist helps Ms. T to establish a daily
routine to prevent jOint, muscle, and skin
breakdowns,
Create The therapist helps her plan regular times to
play with her grandchildren as part of the fam-
ily routine,
son's performance in the natural context. For example,
does the dressing item on a standardized test rate the
person the same way that a therapist would rate the
605
 rerson if watching the person's morning dressing rou-
tine This information will enable occupational therapists
' acuteness of injury, chronicity of disability, or terminal
to construct initial data about persons so that planning
can be individualized and relevant to their needs. It will
also be important to create new, contextually relevant
assessments in the future,
There are also questions that need to be answered
about the prorosed therapeutic interventions. For exam-
ple, which interventions are the best choices for which
performance problems? What is the effect of the pro-
posed therapeutic interventions on performance out-
comes l What is the difference in functional outcomes
when therapeutic interventions occur in natural and con-
trived contexts? It is not likely that all the intervention
options described here will be equally useful for all per-
formance problems. Therefore, it will be important to test
the relationships among particular performance prob-
lems and various intervention Options.
The tendency to take ideas created through profes-
sional dialogue in the literature and regard them as cer-
tainty is tempting; in fact, in dialogue this is easy to do.
Ideas must be tested, and it seems only fitting that ideas
proposed about context be evaluated in that setting. As
knowledge and understanding grow about the rol<: of
context in human performance, these initial proposals
will need adaptation, a suitable outcome for a set of ideas
about ecological relationships .•
Appendix
Ecology of Human Performance: Definitions
Person: An individual with a unique configuration
of abilities, experiences, and sensorimotor,
cognitive, and psychosocial skills.
A. Persons are unique and complex and therefore precise
predictability about their performance is impossible.
B. The meaning a person attaches to task and contextual
variables strongly influences performance.
Task: An objective set of behaviors necessary to
accomplish a goal.
A. An infinate variety of tasks exists around every person.
B. Constellations of tasks form a person's roles.
Performance: Both the process and the result of
the person interacting with context to engage in
tasks.
A. The performance range IS detennined by the interaction
between the person and the context.
B. Performance in natural contexts is different from perform-
ance in contrived contexts (ecological validity, Bronfen-
brenner, 1979).
Context: (Adapted from The AOTA Uniform
Terminology Definition [3rd edition] for context)
is as follows:
Temporal A::,pects (note: although temporal aspects are deter-
mined by the person, they become contextual due to the social
and cultural meaning attached to the temporal features)
1. Chronological: person's age
2. Developmental: stage or phase of maturation.
3. Life cycle: place in important life phases, such as career
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cycle, parenting cycle, educational process.
4. Health status: place in continuum of disability, such as
nature of illness.
5 Period: the measurable span of time during which a task
exists or continues.
Environment
1. Physical: nonhuman aspects of context (includes the natu-
ral terrain, buildings, furniture, objects, tools, and de-
vices).
2. Social: availability and expectations of important persons,
such as spouses, friends and caregivers (also includes larg-
er social groups that are influential in establishing norms,
role expectations, and social routines).
3. Cultural: customs, beliefs, activity patterns, behavior stan-
dards, and expectations accepted by the society of which
the person is a member (includes political aspects such as
laws that shape access to resources and affirm personal
rights; also includes opportunities for education, employ-
ment, and economic support).
Therapeutic intervention: A collaboration
between the person/family and the occupational
therapist directed at meeting performance needs,
Therapeutic interventions in occupational therapy are multifa-
ceted and can be designed to accomplish any or all of the
follOWing.
Establish/restore a person's abilities to perform in context.
Therapeutic intervention can establish or restore person's
abilities to perform in context. This emphasis is on identify-
ing a person's skills and barriers to performance, and deSign-
ing interventions that improve the person's skills and expe-
riences.
Alter actual context in which people perform.
Therapeutic interventions can alter the context within which
the person performs. This intervention emphasizes selecting
a context that enables the person to perform with current
skills and abilities. This can include placing the person in a
different setting that more closely matches current skills and
abilities, rather than changing the present setting to accom-
modate needs.
Adapt contextual features and task demands so they support
performance in context.
Therapeutic interventions can adapt contextual features and
task demands so they are more supportive to the person's
performance. In this intervention, the therapist changes as-
pects of context and/or tasks so performance is more possi-
ble. This can include enhancing some features to provide
cues, or reducing other features to ret.luce distractibility.
Prevent the occurrence or evolution of malpractice perform-
ance in context.
Therapeutic interventions can prevent the occurrence or
evolution of barriers to performance in context. Sometimes,
therapists can predict that certain negative outcomes are
likely without intervention to change the course of events.
Therapists can create intervention to change the course of
events. Therapists can create interventions that address per-
son, context, and task variables to change the course, thus
enabling functional performance to emerge.
Create circumstances that promote more adaptable!complex
performance in context.
Therapeutic interventions can create circumstances which
promote more adaptable performance in context. This
therapeutiC intervention does not assume a disability is pre-
sent or has the potential to interfere with performance. This
therapeutic choice focuses on proViding enriched contexual
and task experiences that will enhance performance.
Jul)! 1994, Volume 48, Number 7
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